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Endovascular Introduction
Endovascular therapy has evolved significantly since its origins in the 1920s. Modern endovascular techniques can now treat nearly all cerebrovascular diseases from within the vessels using catheters, coils, stents, and other devices to occlude or open vessels. The Penumbra system specifically uses a reperfusion catheter and separator to continuously aspirate thrombus in acute ischemic stroke. Case studies demonstrate its effectiveness in restoring blood flow in the MCA, ACA, and other vessels to achieve good patient outcomes.
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Endovascular Introduction
- 1.
- 2. History • 1927 AntonioEgas Moniz • Cerebral angiography • 1960 Luessenhop and Spence • AVM embolization • 1969 Fedor A. Serbinenko • Balloon occlusion of cerebral artery
- 4. History • 1974 Gruntzig& Hopff • Angioplasty for stenotic vessels • 1987 Sigwart • Coronary stent • 1995 Guido Guglielmi : GDC coil
- 5. Present • Endovascular measures • Occlude • coils, liquid and particle embolizers, balloon, stent • Open up • balloon, stent, drugs
- 6. Present • Endovascular therapycan treat • Aneurysm, AVM, AVF, CCF • Intra- and extracranial arterial stenosis • Acute ischemic stroke • Dural sinus thrombosis • Nearly all cerebrovascular diseases can be treated
- 7. Acute stroke • Thrombolysis • intra-venous rTPA • intra-arterial urokinase, rTPA... • mechanical • thrombus aspiration, thrombus buster, stenting
- 9. Penumbra system • CEand FDA certificated • Indication for use (501k document) • Revasculization of patients with acute ischemic stroke secondary to intracranial large vessel occlusive disease within 8 hours of symptom onset
- 10. System Components • ReperfusionCatheter – Optimized design for efficient navigation and aspiration • Separator™ – Operator controlled movement clears Reperfusion Catheter enabling continuous aspiration. • Penumbra Aspiration Pump & Aspiration Tubing – Provides continuous, physiologic vacuum that can be controlled from the sterile field. 10 1274.C
- 11. Aspiration System Matched 041 Separator™ Reperfusion Catheter 041 Matched 032 Separator Reperfusion Catheter 032 Matched 026 Separator Reperfusion Catheter 026 11 1274.C
- 12. Aspiration System Matched 041 Separator™ Reperfusion Catheter 041 Matched 032 Separator Reperfusion Catheter 032 Matched 026 Separator The Penumbra System uses a unique Microcatheter and Separator™ Reperfusion debulking approach to intracranial revascularization. based thrombus Catheterwith the Penumbra Aspiration Pump and Accessories, its Together 026 advantages include: • Proximal working position 11 1274.C • Continuous aspiration
- 14. Budapest Case #3:Exchanged Devices • 041 Reperfusion Catheter tracked into Temporal branch • Became clogged • Removed Separator 041 Separator bulb • Temporal branch opened 13 1274.C
- 15. Budapest Case #3:Exchanged Devices • 041 Reperfusion Catheter tracked into Temporal branch • Became clogged • Removed Separator 041 Separator bulb • Temporal branch opened 13 1274.C
- 16. Patient # 74:Baseline • 67 year old female • Baseline NIHSS: 8 despite right MCA M1 segment occlusion. • Good collateral flow and preservation of lenticulo striates • 7 hrs 10 min from onset to arterial puncture 14 1274.C
- 17. Patient # 74:Post-Penumbra • 041 Reperfusion Catheter and 041 Separator X2 restored flow to distal vascular bed. • 38 min revasc. time • Discharge NIHSS: 0 • 90 Day NIHSS: 0 • 90 Day mRS: 0 • Excellent recovery despite late time to arterial puncture. 15 1274.C
- 18. Patient # 34:Baseline • 70 year old female • History of Afib. • Baseline NIHSS: 14 despite left MCA superior M2 segment occlusion with intact lenticulo striates. • 4 hrs 5 min from onset to arterial puncture 16 1274.C
- 19. Patient # 34:Post-Penumbra • 026 Reperfusion Catheter and 026 Separators X3 efficiently opened small, tortuous M2 • 21 min revasc. time • Discharge NIHSS: 0 • 90 Day NIHSS: 0 • 90 Day mRS: 0 17 1274.C
- 20. Patient # 37:Baseline • 60 year old male • Baseline NIHSS: 12 despite left ACA A3 occlusion • 5 hrs 20 min from onset to arterial puncture 18 1274.C
- 21. Patient # 37:Post-Penumbra • Flow restored • 32 min revasc. time • 026 system reached A3 segment safely • Discharge NIHSS: 1 • 90 Day NIHSS: 1 • 90 Day mRS: 1 • Excellent recovery indicates treatment of A3 occlusion was warranted 19 1274.C
- 23. Stenting • Carotid stent •Vertebral orifice stent • Intracranial stent
- 29. • • 20% • Onyx 50%
- 30. Onyx • Ethylene vinylalcohol copolymer EVOH • Solvent--DMSO - Dimethyl sulfoxide • • •
- 32. Isil Saatci Saruhan Cekirge Ankara, Turkey
- 33. • 350 AVM(158 grade 1-2, 192 grade 3-5) • 179 (51%) complete obliteration • Others • 136 referred to RTO • 27 referred to surgery • 4 discontinued therapy • 5 died
- 34. • Total curerate 178/350 (50.6%) • Mortality rate 1.4% (procedure related 1.1%) • Permanent morbidity rate 7.1% • Permanent closure 98.9%
- 42. Image study • CT •MR • Angiogram • SPECT • PET • Xenon CT
- 43. Image study • Vascularanatomy • 3D reconstruction • Perfusion study • qualitative vs quantitative • Others • phase contrast MR(measure flow rate)
- 44. X-ray • Fluoroscope • Roadmap •Subtraction • Rotation
- 48. What’s different from surgery • From inside the vessels • blood flowing • blood clotting • every vessel is reachable (sort of)
- 49. You need to? •learn • handle X-ray equipments • complete cerebrovascular anatomy • setting up the system • different catheter, wires, stent, coils...
- 50. Taiwan • Neuroradiology •Handle X-ray equipment • Have techniques in angiography • Access to all image modality • Pioneer in this field in Taiwan
- 51. Taiwan • Neuroradiology •no patient care experience • need neurosurgeons backup • more conservative • low income from treatment
- 53.
- 54. Taiwan, French, Australia, Neuroradiologist Brazil, Portugal, Italy Neurosurgeon Japan, Austria Neuroradiologist US, Korea Neurosurgeon Neurosurgeon China Neurologist
- 55. Taiwan • Neurosurgeon •We have patients • Know more of these diseases • More aggressive • More treatment choices • Can negotiate the “insurance issue”
- 56. We can now •Perform all interventional procedure • Use most catheters, wires, balloons • Use ordinary coils, embolizers • Use any stuffs not cover by
- 57. We can not •Apply • Detachable coils ( ) • Carotid stent ( )
- 58. Coil • • • • •
- 60. Neurosurgery Surgery Endovascular Combined 30 24 22 20 18 17 16 12 13 12 8 6 4 2 0 1995 2000 2005 Number of papers related to treatment of vascular disease
- 61. Cerebrovascular Dz 5% Hemorrhagic 25% Ischemic 70% Ischemic Hemorrhagic Others
- 62. CCF Surgical treatment Aneurysm Many Years ago Spinal AVM Malignant infarction Carotid stenosis DAVF, EC-IC AVM ICH
- 63. Surgical treatment Aneurysm Now Spinal AVM Malignant infarction AVM CCF ICH Aneurysm Spinal AVM Carotid stenosis DAVF AVM Endovascular treatment
- 64. Surgical treatment Future Malignant infarct EC-IC ICH CCF, ICH Aneurysm Spinal AVM Carotid stenosis DAVF, AVM And......... Endovascular treatment
Editor's Notes
- #21 Dural sinus thrombosis with impaired vision. s/p thrombolysis and sinus stent. Vision improved after treatment